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Recent Publications by our members:
At the KYSAM annual symposium in Lexington in October, Richard Cales, MD, FASAM, presented an investigation with his faculty colleagues from the University of Louisville Department of Emergency Medicine that was published in November in the Harm Reduction Journal.
Titled “Harm reduction in the fourth wave of the opioid epidemic: A case series investigation of the effectiveness of definitive vs presumptive urine drug testing for opioid use disorder with co-occurring polysubstance use,” the research is the first published investigation of ASAM’s 2017 guidelines for “smarter” drug testing as delineated in their “Appropriate Use of drug test in clinical addiction medicine. Additionally, it is also the first published investigation of the potential benefits of using near-real-time clinical laboratory testing to manage clinical decision-making for individual patients in real-world community settings—as suggested by NIDA director Dr. Nora Voklow in her 2023 editorial perspective in the New England Journal of Medicine.
As summarized in the presentation at the annual symposium, the investigation offers addiction medicine clinicians treating substance use disorders three substantive takeaways:
• Although point-of-care immunoassay (IA) testing may suffice for population-based screening (initial detection and referral), MOUD decision-making (diagnosis, treatment, harm reduction) is better served by near-real-time laboratory mass spectrometry (MS) testing.
• The team’s experience with “smarter” drug testing demonstrates that using non-quantitative MS for testing all urine samples virtually eliminates the need for routine IA testing—which requires confirmatory testing of more than half (57.6%) of all IA tests due to one or more positive presumptive findings in polysubstance users—yet costs only $10 more per patient encounter than using IA in conjunction with MS confirmation.
• These findings have facilitated the opportunity to integrate MOUD with harm reduction by adopting smarter MS testing protocols that enable clinicians to detect emerging and novel substances, ie, kratom, xylazine, carfentanil, dexmedetomidine, tianeptine, levamisole, bromazolam, and nitazenes.
The published article can be downloaded Open Access from the Harm Reduction Journal at https://rdcu.be/eQxop free of charge (no subscription or paywall).
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South A, Hawk K, Friedman S. Lofwall M, Fanucchi L, and Cohen S. Civil Rights Laws for People With Opioid Use Disorder in the Emergency Department. J Addict Med. 19(6). Nov/Dec.2025. pp. 643-647.
The authors note that under federal civil rights laws, it is illegal to discriminate against people with opioid use disorder. Discrimination may include failure to screen for an undiagnosed opioid use disorder and offer medications or opioid use disorder alongside a facilitated referral for outpatient treatment. Yet in Kentucky < 20% of EDs have a process to link people to care or MOUD. Less than one third of people with OUD treated for a nonfatal overdose in the ED receive MOUD or a follow-up appointment. The authors note that EMTALA requires hospitals to provide a medical screening exam to every ED patient, identify emergency medical conditions, and provide treatment to stabilize the patient to reasonably ensure that their medical condition does not deteriorate post discharge. It is a violation of this law when EDs fail to screen patients for OUD, offer and administer MOUD as appropriate and provide a facilitated referral for care. The authors recommend that EDs streamline and increase MOUD initiation and ensure that buprenorphine and methadone are on the hospital formulary. They need to develop and initiate protocols for MOUD initiation and continuation in the ED and develop relationships with local buprenorphine prescribers and OTPs. EDs should institute mandatory education on evidence-based practices in the treatment of MOUD. Some of the reluctance to initiate MOUD in the ED is related to stigma as demonstrated in surveys about attitudes of ED personnel towards patients with OUD. Patients could file a civil rights violation claim if they are not allowed access to evidence-based appropriate ED care for OUD.
Click here to read the article.
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The latest edition of the American Journal on Addictions contains a brief case report out of Sao Paulo Brazil authored by Mariana C de Oliveira, MD, Claudia C Araujo Palmeira, PhD, et.al. (Brief Report: Ketamine-assisted "bridge therapy" for opioid tapering in complex cases) regarding the use of IV ketamine to treat depression and facilitate taper of methadone. The patient was a 25-year-old woman who had a long history of chronic pain. She had been prescribed multiple opioids since her teenage years. As often happens, she became tolerant, started escalating her dose, and eventually met criteria for opioid use disorder. She was started on methadone for pain management and OUD but began abusing the methadone. She also developed major depressive disorder which was not responding to multiple trials of antidepressants. She was admitted to a specialized treatment program for pain and opioid use disorder. The treatment team struggled to distinguish pain related to a nociceptive or neuropathic condition versus pain from a nociplastic condition (pain coming from altered pain processing in the central nervous system rather than nerve injury) exacerbated by emotional factors.
The team opted to initiate IV ketamine primarily because of her major depressive disorder, but also with the hope that her methadone dose could be tapered. She received eight 45- minute infusions of IV ketamine weekly over 8 weeks. After a 2-week stabilization period, tapering of her methadone dose was initiated. It was tapered by 25% every 2 weeks. By the end of the treatments, she was down to 30 mg. She did not experience any craving for ketamine. The methadone was then gradually discontinued over the next 6 months after ketamine treatments ended.
Clinical improvement occurred in multiple areas. Her pain improved. The Brief Pain Inventory score dropped from 7 to 2. The PHQ9 dropped from 17 to 4 after the first treatment and remained steady during the treatments. Health related quality of life improved, and as her mood improved, she became more receptive to psychotherapy and to tapering the opioid further.
There have been other reports of ketamine being used for opioid withdrawal. A systematic review by Shen et.al. (https://pubmed.ncbi.nlm.nih.gov/40370588/) published in 2025 in Front Psychiatry found that use of ketamine was well tolerated and associated with decreased craving, severity of withdrawal, and depressive symptoms. They note that ketamine was used here as a bridge therapy to facilitate tapering from high dose opioid therapy to lower doses, decreasing symptom burden and enhancing motivation for change.
The authors point out that more research is needed. This was a case study of a single patient whose history is unique in that she was not using illicit opioids or other substances. She was treated in a specialty clinic where infusions were closely monitored. Ketamine was used for a time-limited, specific purpose. How this would apply to the larger patient population of persons with OUD is not yet clear.
https://pubmed.ncbi.nlm.nih.gov/41607036/
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